better health for mothers and children: breastfeeding ... · 1 we ignore wet nursing in this report...

Better Health for Mothers and Children: Breastfeeding Accommodations under the Affordable Care ActBy Robert Drago, Ph.D., Jeffrey Hayes, Ph.D., and Youngmin Yi

About This Report

This study examines new workplace protections for nursing mothers under federal law. We report current patterns of breastfeeding, and provide the first estimates of coverage rates under the law, as well as the first projections of the likely effect of the new protections on increasing rates of breastfeeding in the United States. The research represents part of a broader body of work undertaken by the Institute for Women’s Policy Research on balancing work and family commitments. The research was made possible by grants from the Annie E. Casey Foundation, the Ford Foundation, the Kellogg Foundation, and the Rockefeller Foundation.

About the Institute for Women’s Policy Research

The Institute for Women’s Policy Research (IWPR) conducts rigorous research and disseminates its findings to address the needs of women, promote public dialogue, and strengthen families, communities, and societies. The Institute works with policymakers, scholars, and public interest groups to design, execute, and disseminate research that illuminates economic and social policy issues affecting women and their families, and to build a network of individuals and organizations that conduct and use women-oriented policy research. IWPR’s work is supported by foundation grants, government grants and contracts, donations from individuals, and contributions from organizations and corporations. IWPR is a 501 (c) (3) tax-exempt organization that also works in affiliation with the women’s studies and public policy programs at The George Washington University.

Acknowledgments

Many people facilitated this research and provided significant insight into issues surrounding breastfeeding, employment, and relevant legal issues, including Melissa Bartick of the Harvard Medical School and Laurie Bonjo of Old Dominion University. We thank them and we are responsible for any inadvertent errors.

IWPR B292$10.00© Copyright 2010 by the Institute for Women’s Policy Research, Washington, DC.All rights reserved. Printed in the United States of America.

Board of Directors

Lenora Cole, ChairUniversity of Maryland University College

Esmeralda O. Lyn, Vice ChairHofstra University

Carol Greene Vincent, TreasurerPricewaterhouse Coopers LLP

Cynthia Lloyd, SecretaryPopulation Council

Bill BaerBloomingdale’s

Mariam ChamberlainNational Council for Research on Women

Bob CortiAvon Foundation

Ellen DelanyDelany, Siegel, Zorn & Associates, Inc.

Holly FechnerCovington & Burling LLP

Lynn GitlitzBusiness Development Consultant

David A. GoslinAmerican Institutes for Research

Ellen KarpAnerca

Susan MeadePhillips Oppenheim

Emily van AgtmaelVan Agtmael Interiors

Sheila W. WellingtonNew York University

Marcia Worthing

Heidi Hartmann, PresidentInstitute for Women’s Policy Research

Barbara Gault, Vice PresidentInstitute for Women’s Policy Research

Institute for Women’s Policy Research1200 18th Street NW, Suite 301

Washington, DC 20036202/785-5100 • 202/833.4362 fax

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Table of Contents

List of Figures ................................................................................................................. i

Executive Summary ...................................................................................................... iii

Background ..................................................................................................................1

Breastfeeding, Infant Formula, and Breast Milk Expression ........................................1

Employment Is a Barrier ..........................................................................................2

Interventions Can Raise Rates of Breastfeeding .........................................................4

The Affordable Care Act Will Help ..........................................................................4

Rates of Breastfeeding Prior to the Health Care Reform ..................................................5

ACA Coverage by Income, Education, Age, and Race/Ethnicity ......................................8

Projected Effects of the ACA on Breastfeeding Rates .................................................... 12

Further Considerations ................................................................................................ 14

References .................................................................................................................. 16

Appendix: Data and Methodology .............................................................................. 19

List of Figures

Figure 1. Infants Ever-Breastfed, Selected Nations ...........................................................3

Figure 2. Poverty and Breastfeeding ...............................................................................6

Figure 3. Education and Breastfeeding ...........................................................................6

Figure 4. Age and Breastfeeding ....................................................................................7

Figure 5. Race/Ethnicity and Breastfeeding ....................................................................7

Figure 6. ACA Coverage Among Employed Women .......................................................9

Figure 7. Poverty and ACA Coverage ........................................................................... 10

Figure 8. Education and ACA Coverage ....................................................................... 10

Figure 9. Age and ACA Coverage ................................................................................. 11

Figure 10. Race/Ethnicity and ACA Coverage ............................................................... 11

Figure 11. Breastfeeding Effects of ACA Coverage Among Employed Mothers ............... 13

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Executive Summary

Given a choice between breastfeeding and using infant formula, most new mothers

select breastfeeding. Employment, however, has often constrained this choice,

obliging mothers to use formula. In recent decades, an additional option has emerged:

expressing breast milk in the workplace and storing it for later use. This option spares

new mothers from having to choose between breastfeeding and employment.

Although no hard numbers are available on the extent of breast milk expression,

indirect evidence suggests that the practice is increasingly recognized as viable and

valued. Most recently, the U.S. Congress passed, and President Obama signed, the

Affordable Care Act of 2010 (ACA), which provides for nursing breaks and a private,

sanitary place for most mothers employed on an hourly basis to express breast milk

(PPACA 2010).

The new ACA breastfeeding provisions raise several questions that are answered below:

• How many women breastfeed? How is breastfeeding affected by employment?

How do levels of breastfeeding and employment differ among mothers across

lines of income, education, age, and race/ethnicity?

• How many employed women of childbearing age are covered by the new ACA

provisions? Who among the different demographic groups are covered?

• How many mothers are likely to breastfeed an infant through six months of age

as a result of the provisions?

Our analysis shows that:

• Women in a relatively weak position in the labor market, including those who

are poor, young, do not hold a college diploma, and who are African American,

are those who historically have had low rates of breastfeeding, according to

data from the U.S. Centers for Disease Control and Prevention (CDC) (National

Center for Health Statistics 2010).

• Mothers in similar groups, including those who are poor, young, do not hold a

college diploma, or are Hispanic or African American, are most often covered

by ACA workplace breastfeeding protections. This first estimate of coverage is

based on an analysis of the 2009 Annual Social Economic Supplement (ASEC)

to the Current Population Survey (CPS).

• The ACA provisions therefore appropriately target mothers who are most likely

to benefit from the provisions.

• An estimated total of almost 19 million employed women of childbearing

age are covered by the ACA provisions. That figure is likely an underestimate

of effective coverage, given that many salaried women who are not formally

covered by this provision in the ACA work alongside hourly workers who are.

• Based on an analysis of the 2009 ASEC data, a first cautious projection of

the effects of the ACA on rates of breastfeeding is that an additional 165,000

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mothers annually will breastfeed until an infant is at least six months old.

Although the estimate represents only a four percentage point increase in rates

of breastfeeding among all mothers of infants, more than one million mothers

and their children will be affected over the course of the next six years, with

attendant health benefits for both mothers and infants. Longer-term effects due

to any reduced stigma attached to breastfeeding and breast milk expression

could raise these figures.

• Results from an earlier study suggest that slightly more than 25,000 mothers

living in poverty do not breastfeed their infants through six months because of

stringent work requirements under the Temporary Assistance to Needy Families

(TANF) program (Haider, Jacknowitz, and Schoeni 2003, p. 492). Our estimates

suggest that an overlapping group of 16,500 mothers living in poverty will

likely breastfeed as a result of the ACA provisions, partly redressing some of the

effects of welfare reform.

Additional policy options for reducing remaining constraints on the choice to

breastfeed are also discussed:

• legalizing breastfeeding in public places,

• introducing health and safety standards for breast pumps, and

• subsidizing breast pumps and breastfeeding counseling and education.

www.iwpr.org 1 1 We ignore wet nursing in this report for brevity.

Background

Breastfeeding, Infant Formula, and Expressing Breast Milk

The rise of the infant formula market in the early part of the 20th century provided new

mothers with a choice between breast and bottle feeding.1 In the United States, popular

portrayals of infant formula in the 1960s and 1970s cast it as “liberation in a can,”

partly because it facilitated a more equal division of household labor between mothers

and fathers but also because it made it easier for new mothers to be employed (Galtry

2000, p. 301).

Effectively, there was, and to some extent still is, a line between breastfeeding and

employment, as documented below. That line, however, was already breaking down

during the 1990s, and perhaps earlier, due to the emergence of a third option:

expressing breast milk in the workplace and storing the milk for later use. Although no

hard numbers are available on the extent of expressing breast milk, indirect evidence

suggests the practice is increasingly recognized as viable and valued. In 1997, the

American Academy of Pediatrics (AAP) issued a policy statement that, in part, urged

employers to support expressing breast milk at work. A year later, Representative

Carolyn Maloney introduced a bill in the U.S. Congress explicitly supporting the

practice (Galtry 2000). By 2000, the International Labour Organization (2000) issued

a Maternity Protection Convention, which included a provision for paid nursing breaks

or reduced work hours to allow new mothers to breastfeed. According to National

Survey of Employer data from the Families and Work Institute, the percentage of U.S.

employers providing a private space or lactation room for this purpose rose from 37

percent in 1998 to 53 percent in 2008 (Galinsky, Bond and Sakai 2008). Most recently,

the U.S. Congress passed, and President Obama signed, the Affordable Care Act of

2010 (ACA), which provides for nursing breaks and a private, sanitary place for many

employed mothers to express breast milk.

Recent studies documenting the benefits of breast milk for children, for mothers, and

for society at large are central to understanding the ascendance of breastfeeding in

general and breast milk expression. Researchers have estimated that if 80 percent of

U.S. infants were breastfed exclusively for six months, health care expenditures would

decline by $10.5 billion, and 741 annual infant deaths would be prevented (Bartick

and Reinhold 2010). According to the AAP, breastfeeding helps to protect infants from

asthma, obesity, diabetes, childhood leukemia, sudden infant death syndrome, and

diarrhea, and may lead to better health later in life (AAP 2005). Nursing also improves

mothers’ ability to recover from childbirth, and may decrease mothers’ risk of breast

cancer, ovarian cancer, type II diabetes, (Ip et al. 2007) and cardiovascular disease

(Schwarz et al. 2009). These studies and related public health initiatives motivated

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many new mothers to switch from infant formula to breastfeeding, including expressing

breast milk at work and storing it to feed her infant at later times.

There is uncertainty regarding the importance of exclusive breastfeeding as opposed

to augmenting breast milk with water, baby food, formula, juice, cow’s milk, or sugar

water. The cost-benefit study mentioned above restricted its analysis to exclusive

breastfeeding as part of a careful scientific approach because it is difficult to parcel out

health effects when various amounts or degrees of breastfeeding are involved (Bartick

and Reinhold 2010). Additionally, the World Health Organization (2002) and the AAP

(2005) recommend exclusive breastfeeding as a standard for the care of all infants.

The signature public health initiative in the United States addressing breastfeeding,

the Healthy People 2010 (HP2010) initiative from the U.S. Department of Health

and Human Services (HHS) (DHHS 2000), initially focused on the value of any

breastfeeding, regardless of supplementation. Starting from a 1998 baseline wherein

64 percent of new mothers initiated breastfeeding post-partum, 29 percent continued

for at least six months, and 16 percent continued for one full year, the HP2010 target

for the year 2010 was to raise these rates to 75 percent, 50 percent, and 25 percent,

respectively. Partly due to related campaigns to promote breastfeeding, one of the

HP2010 targets was met by mid-decade: the percentage of infants who were ever

breastfed rose from 60 percent in 1993–1994, to 77 percent in 2005–2006 (CDC

2007). Nonetheless, only 43.5 percent of infants in the United States were at least

partially breastfed2 for the first six months of life among children born in 2006, and 23

percent were partially or exclusively nursed for an entire year (CDC undated).3 As a

practical matter, the original HP2010 emphasis on any breastfeeding is sensible: only

one-third of mothers nursing through six months do so with no supplementation.4

Employment Is a Barrier

Although the HP2010 goal of raising the proportion of infants ever breastfed was met

successfully, it failed to achieve two of the three objectives. One set of reasons for

this failure has to do with physical difficulties and health risks involved in establishing

or maintaining breastfeeding (DHHS).5 For women who confront these issues,

breastfeeding may be neither desirable nor possible.

2 Exclusive breastfeeding implies that no other foods or liquids are provided to the infant during this period. Note that expressing and storing breast milk is consistent with exclusive breastfeeding. 3 Only 22.7 percent of the infants were breastfed for an entire year.4 The CDC figure for any breastfeeding at six months is above 43 percent, whereas the WHO Global Data Bank on Infant and Young Child Feeding reports a figure of only 13.6 percent of U.S. infants being exclusively breastfed through six months. See http://www.who.int/nutrition/databases/infantfeeding/countries/usa.pdf. Note that the HHS introduced exclusive breastfeeding targets in 2007, and the target for six months as of 2010 was only 25 percent, half the size of the target for any breastfeeding at six months (CDC 2007). 5 Some new mothers may be unable to produce breast milk. The presence of certain health conditions, including HIV or other infectious diseases, might also warrant that the mother not breastfeed.

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Nonetheless, the United States exhibits one of the lowest rates of breastfeeding in a

sample of nations providing comparable data on whether infants are ever breastfed

(Figure 1). It seems unlikely that physical difficulties establishing or maintaining

breastfeeding are so different in the United States, implying that some other barrier is

relatively unique to the United States.

Research suggests that a key reason for low U.S. rates lies in employment. All of the

nations listed in Figure 1 provide paid maternity leave, except for the United States.

American mothers who plan to continue their jobs are therefore forced to make a

relatively rapid return to employment (McGill Institute for Health and Social Policy

2010). Studies specific to the United States show that rapid return to employment is

correlated with stopping nursing. One study found that women employed four months

after childbirth breastfed for an average of 18 weeks, compared to a figure of almost

26 weeks for nonemployed mothers (McKinley and Hyde 2004). Another study found

that stringent work requirements for mothers of infants under Temporary Assistance

to Needy Families (TANF), a welfare-to-work program introduced in 1996, affected

2.6 percent of new mothers and, as a result, almost half of these mothers (1.2 percent

of all new mothers) abandoned breastfeeding by the time their infant was six months

old (Haider, Jacknowitz and Schoeni 2003). Using 2006 birth rates (presented below),

this yields an estimate of more than 25,000 infants who are not breastfed each year

because their mothers are poor and subject to work requirements under TANF.

Source: World Health Organization Global Data Bank on Infant and Child Feeding, most recent years available. <http: //www.who.int/nutrition/databases/infantfeeding/countries/en/index.html>

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Figure 1: Infants Ever-Breastfed, Selected Nations

99 97 95 94 93 92 9076 74

Norway

United

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gdom

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ico

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Interventions Can Raise Rates of Breastfeeding

As the rise of expressing breast milk at work implies, breastfeeding and employment are

not inherently incompatible. New mothers with part-time as opposed to full-time jobs

are more likely to continue breastfeeding once employment resumes (Fein and Roe

1998), as are mothers who perform at least some work at home under telecommuting

arrangements (Jacknowitz 2008). In both of these cases, work arrangements may

facilitate the scheduling of breastfeeding around time devoted to the job.

Other mothers express breast milk in the workplace. As mentioned earlier, employers

have increasingly provided relevant accommodations in recent years (Galinsky, Bond

and Sakai 2008).

More generally, workplace supports can improve the fit between employment and

breastfeeding. Although the availability of schedule adjustments and lactation rooms

have been found to encourage breastfeeding, according to a recent study, new mothers

with flexible work schedules also tend to breastfeed longer, and continue to do so after

returning to work (Guendelman et al. 2009). A study of 462 new mothers employed

across five corporations found that an intervention involving breastfeeding education

and counseling in tandem with a private lactation room and a breast pump raised rates

of breastfeeding initiation to 98 percent, with 58 percent of the mothers continuing

at least partial breastfeeding for six months or longer—well above the HP2010 target

(Ortiz, McGilligan and Kelly 2004).

Other aspects of the aforementioned study are noteworthy. First, 94 percent of the

women returned to their original jobs after the baby was born. Second, of that group,

79 percent attempted to express breast milk at work, and almost all of those who tried

succeeded (98 percent). Among those who succeeded and did not stop working, the

mean duration of breastfeeding was more than nine months. That group represented 76

percent of the women who had returned to the job after childbirth.

The Affordable Care Act Will Help

Employment can be made compatible with breastfeeding, and targeted legislation

could facilitate that process. One relevant response lies in the Breastfeeding Promotion

Act, introduced by Representative Carolyn Maloney in each session of Congress since

1998. In 2010, two related provisions were included in the Affordable Care Act (ACA):

the right for new mothers to have reasonable break times and the right to a private

place to express breast milk at work until the child is one year of age. The law applies

only to “nonexempt” employees, or those covered by the overtime provisions of the

Fair Labor Standards Act (FLSA). U.S. Department of Labor rules regarding the ACA

were issued in July 2010, and specify that employers with fewer than 50 employees

can be exempted from the ACA requirements if “compliance with the provision would

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impose an undue hardship” on the employer (2010).6 The rules also specify that

employers with multiple worksites must count all employees across the sites as a single

group. This requirement implies that employees in many small establishments will also

be covered by the ACA protections.

In conducting this study, we hypothesize that the ACA will promote nursing among

mothers who have been least likely to breastfeed in the past. The law covers

employees in hourly as opposed to salaried jobs (see Appendix), and these jobs are

typically low-wage, are those for which time-cards are still used, where supervision

is often strict, and where too many breaks for any reason can result in dismissal.

Therefore, it is expected that women holding these positions have faced extreme

difficulties in attempting to combine breastfeeding and employment. Similarly, the

overtime protections provided to workers by the FLSA when it was passed in 1938

were intended to restrain employers from abusing workers who were disadvantaged

relative to high-wage managers and professionals. Both the original purpose of the

FLSA and that underlying the new ACA breast milk expression provisions may serve

to protect employees who are most in need of protection. In what follows, we use

poverty, education, age, and race/ethnicity as proxies for socioeconomic status (SES),

and assume that women of low SES are those facing the most severe barriers to

breastfeeding, and hence are those who will benefit most from the new protections.

Following those analyses, we project the effect of the ACA on increasing rates of

breastfeeding.

Rates of Breastfeeding Prior to the Health Care Reform

The most recent estimates for rates of breastfeeding are provided in a CDC analysis

of National Immunization Survey data covering children born in 2006 (undated). The

estimates are for women who breastfed infants the first six months of the child’s life,

regardless of whether breast milk is supplemented with other foods or liquids, and

whether or not the mother was employed.

Figure 2 describes the relationship between family income and rates of breastfeeding.

It shows that new mothers living in poverty are only around two-thirds as likely to

breastfeed relative to their counterparts in families with income at or above 350

percent of the poverty line. Breastfeeding is a practice tied to households with high

family income.

6 The Department of Labor intends to issue additional guidance regarding the breast milk expression provisions of the ACA. Until further guidance is released, we will not know for certain whether small employers will need to apply for any exemption or can instead assume the exemption applies unless an employee files a complaint with the Wage and Hour Division.

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Figure 3 provides information on educational attainment and rates of breastfeeding.

New mothers who hold degrees from a four-year college or university are almost twice

as likely to breastfeed as those with education levels equivalent to or less than a high

school diploma. Breastfeeding is linked to high levels of education.

Figure 4 links breastfeeding to the age of the mother at childbirth. New mothers under

the age of 20 years are less than half as likely to breastfeed compared with the group

30 years and older. Breastfeeding and age are positively correlated; older women

breastfeed more.

High school or less Some college or Associates degree

College graduateor more

Educational Attainment

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Figure 3: Education and Breastfeeding

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Source: Figures for mothers of children born in 2006 from CDC analyses of the National Immunization Survey (undated).

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Family Income as % of Poverty Rate

Figure 2: Poverty and Breastfeeding

4351


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Figure 5 provides information on breastfeeding and the race/ethnicity of the mother.

For simplicity, the categories for whites and for African Americans are restricted to non-

Hispanics. Rates are relatively high for whites, and even higher for Hispanics, but are at

least 16 percentage points lower for African American mothers. Breastfeeding is linked

to race and ethnicity.

In general, these patterns support Galtry’s (2000) finding that breastfeeding in the

United States is largely reserved for women of high SES, as reflected in high rates for

new mothers living in high-income families, and among new mothers with high levels

of education, and among those who are white. The age result is also consistent with

29

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Hispanic

% B

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Race/Ethnicity

Figure 5: Race/Ethnicity and Breastfeeding

45


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< 20 years 20 - 29 years 30 or more years

% B

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Figure 4: Age and Breastfeeding


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this interpretation because highly educated women with managerial and professional

careers are those who are most likely to delay childbirth until later in life (Drago 2007).

High rates of breastfeeding among Hispanic mothers do not fit this claim, and may

reflect either cultural influences on rates of breastfeeding or the fact that Hispanic

mothers of infants are less often employed than those who are white or African

American (Han et al. 2008).

There are at least three possible explanations for the linkage between high SES and

breastfeeding. First, highly educated women may more often be exposed to public

health initiatives regarding the benefits of breastfeeding, and hence more likely to

breastfeed in response. If this is true, then equity concerns suggest that we direct

relevant public health initiatives to focus on low-income families, new mothers with

low levels of education, young mothers, and women of color. Second, critics argue

that breastfeeding has become stylish among women of high SES, generating intense

levels of peer pressure in support of breastfeeding among “upper-class women” in

the United States (Rosin 2009). If this is so, then the breastfeeding choices of mothers

of low SES more accurately represent rational behavior. Third, it is possible that the

resources available to mothers of high SES serve to reduce or alleviate constraints on

the breastfeeding choice (e.g., if they can more readily afford to work reduced hours

or delay any return to employment, or if employees with managerial or professional

careers are more likely to have a flexible schedule or a private office for expressing

breast milk). The crossnational comparison of rates of breastfeeding presented earlier

imply that the first explanation, exposure to public health information, may have some

salience, but that the second explanation concerning peer pressure can only hold if

high rates of breastfeeding in other nations reflect a fad of worldwide proportions.

The third explanation, regarding constraints on breastfeeding, strikes us as the most

powerful, particularly given the relatively rapid return to employment found among

mothers in the United States.

ACA Coverage by Income, Education, Age, and Race/Ethnicity

Although the breastfeeding figures above cover all mothers of infants, the ACA

protections are relevant only to employed mothers with infants under one year of age.

As of 2001, around 60 percent of all U.S. mothers returned to employment by the

time the infant reached that age (Han et al. 2008). We analyze coverage rates only

for women who are employed as wage and salary workers and are of childbearing

age (i.e., between 16 and 44 years, inclusive). Although some births may occur at or

beyond the age of 45 years, the absolute number is likely very small, making the group

less relevant for analysis here.

In this first study of coverage rates, the 2009 Social and Economic Supplement (ASEC)

to the Current Population Survey is used to generate coverage estimates (U.S. Census

Bureau 2010) . To provide a cautious estimate, we assume that only hourly workers

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are covered by the ACA provisions, with salaried employees excluded. This assumption

likely yields a substantial understatement of ACA coverage, partly because the overtime

provisions of the FLSA cover some salaried workers (see Appendix). In addition, many

and perhaps most lactation rooms provided to hourly workers will be located in

workplaces that also employ salaried workers. It seems reasonable to believe that the

rooms would only rarely be restricted to hourly workers, effectively expanding facilities

coverage (if not breaks per se) to a proportion of salaried employees. There is also a

hardship exemption for small establishments, but the language on what constitutes a

hardship exemption is vague. In order to approximate the effect the exemption could

have on women, we exclude establishments of 10 or fewer employees (see Appendix).

According to an analysis of these data, we estimate that among the women between 16

and 44 years old employed as wage and salary workers in 2009, 53 percent are now

covered by the ACA workplace breastfeeding protections (Figure 6). In other words,

18.7 million of 35.4 million employed women of childbearing age are covered by the

breastfeeding protections under the recent health care reform.

Almost 19 million women are now covered by the breastfeeding provisions of health

care reform. Millions of salaried workers will likely benefit as well.

First-ever estimates of ACA coverage among employed women across lines of income,

age, education, and race/ethnicity are provided in Figures 7 through 10. The provisions

cover most employed women living in families below 350 percent of the government

poverty line. Indeed, a full three-fifths of these employees are estimated to be covered,

compared with only 44 percent of employees in higher-income families (Figure 7).

Not covered47%

Figure 6: ACA Coverage AmongEmployed Women

Covered53%

Not covered47%

Figure 6: ACA Coverage AmongEmployed Women

Covered53%

Source: IWPR estimates from the 2009 ASEC (U.S. Census Bureau 2010).

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As shown in Figure 8, breastfeeding protections in the ACA mainly cover women

with lower levels of education. Over three-fifths of women with some college or less

education are covered, while just under one-third of college graduates are covered. The

age distribution of coverage favors young women, with coverage extending to almost

three-quarters of those under 20 years of age, three-fifths of those in the age range

20–29 years, and 46 percent of employed women in the 30–44 year age group (Figure

9). Finally, coverage rates by race are relatively low for white women (51 percent),

with higher rates for Hispanic women (57 percent), and the highest rates for African

American women (61 percent, Figure 10).

63

High school or less Some college or Associates degree

College graduateor more

% C

over

ed

Educational Attainment

Figure 8: Education and ACA Coverage

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Source: IWPR estimates from the 2009 ASEC, women below age 45, wage and salary workers only. (U.S. Census Bureau 2010)

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% C

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Family Income as % of Poverty Rate

Figure 7: Poverty and ACA Coverage

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These differences in coverage rates under health care reform uniformly suggest that, as

hypothesized, mothers of low SES are those who are most likely to be covered.

ACA protections for expressing breast milk in the workplace will serve to equalize

opportunities for breastfeeding across lines of socioeconomic status. Employment and

breastfeeding will be more complementary for those who historically have faced the

greatest challenges combining these activities.

African American,not Hispanic

51

% C

over

ed

Figure 10: Race/Ethnicity and ACA Coverage

61 57

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Race/Ethnicity


7060

46

01020304050607080

< 20 years 20 - 29 years 30 - 44 years

% C

over

age

Age in years

Figure 9: Age and ACA Coverage

Source: IWPR estimates from the 2009 ASEC, women below age 45, wage and salary workers only.

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Projected Effects of the ACA on Breastfeeding Rates

The translation of coverage into projected effects on breastfeeding rates at six months

requires several steps. As of 2006, the Census Bureau estimated that 4.2 million

American women gave birth (Dye 2008). A conservative estimate is that 2.1 million

of those mothers (50.4 percent) were employed by the time the infant was six months

old, and that 1.1 million of the employed mothers (52.9 percent), the average rate we

estimated above, would have been covered by ACA breastfeeding provisions, had they

pertained in 2006 (see Appendix).

Employed mothers breastfeed at a rate approximately 15 percent below that of

nonemployed mothers, so we estimate that the rate of breastfeeding among employed

mothers was 36 percent prior to the ACA, and the figure for nonemployed mothers was

51 percent in 2006 (see Appendix). Relative to the hourly employees now covered by

the ACA, the 36 percent estimate is overstated, given it includes numerous women who

are employed on a salaried basis and hence more likely to breastfeed (consistent with

results above).

To the best of our knowledge, only one published study, the research covering an

intervention to promote expressing breast milk across five corporations referenced

earlier, distinguishes the effects of the intervention on hourly as opposed to salaried

employees (Ortiz, McGilligan and Kelly 2004). That study reported that 79 percent

of salaried employed mothers, but only 66 percent of hourly employed mothers

attempted to express breast milk in the workplace. ACA protection is a less extensive

intervention than that used for the 2004 study. That intervention also involved providing

information, counseling, and breast pumps to mothers. Therefore, we estimate that ACA

coverage will yield half the effect of the more extensive intervention, or raise the rate of

breastfeeding at six months among covered mothers from 36 to 51 percent (i.e., half the

increase involved in moving from 36 to 66 percent).

Combining our coverage estimates and our review of breastfeeding rates in the existent

literature allows us to project the net effect of the ACA for the first time. We project

that an additional 165,000 mothers will breastfeed through six months each year

(Figure 11), or more than one million additional mothers and their children in the

next six years will benefit from the health gains due to breastfeeding. As a result, the

rate of breastfeeding at six months will rise from 44.5 to 47.5 percent, or by four full

percentage points, and come closer to the HP2010 goals.

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913,500

1,021,500

165,000

Figure 11: Breastfeeding Effects of ACA Coverage Among Employed Mothers

Already Breastfed

Do Not Breastfeed

Breastfeed Due to ACA

913,500

1,021,500

165,000


Already Breastfed

Do Not Breastfeed


Source: IWPR estimates of average of rates for any breastfeeding at six months from various sources (see Appendix).

913,500

1,021,500

165,000


Already Breastfed

Do Not Breastfeed


By way of comparison, the study of work requirements under TANF estimated that

almost 50 percent of new mothers subject to stringent work requirements abandoned

breastfeeding by six months as a result, a behavioral shift affecting more than 25,000

mothers each year. We estimate that an additional 15 percent of new mothers covered

by the ACA provisions will respond by breastfeeding through six months. The net

effect of the ACA provisions is much larger because it covers almost one-quarter of all

mothers of infants, while stringent work requirements under TANF affected less than 3

percent of new mothers.

Digging a little deeper, we estimate from the ASEC data that 10.2 percent of women

covered by the ACA provisions live in poverty. Therefore, if the provisions lead 165,000

new mothers to breastfeed annually, it is reasonable to infer that 16,500 of these

women will be living in poverty. This shift will in part reverse the adverse effects of

TANF work requirements (although it is important to note that most mothers living in

poverty are not currently receiving income from TANF, so are not subject to related

work requirements; Henrici et al. 2010).

We believe that this projection is both reasonable and cautious. We project that the

behavior of only 4 percent of all new mothers will be influenced by ACA coverage.

However, it seems likely that the behavior of many other new mothers is also likely to

be affected by the law, so that we are likely underestimating the probable behavioral

shift that will ultimately result from the ACA. In part, the understatement follows from

the fact that numerous salaried women will enjoy the benefits of lactation facilities

mandated for hourly employees. The understatement also flows from the fact that many

salaried women are in fact covered by the overtime provisions of the FLSA and hence

the new ACA provisions. Most importantly, it seems likely that the stigma currently

attaching to breastfeeding in general and especially to expressing and storing breast

www.iwpr.org14

milk at the workplace7 will be attenuated by the provision in the ACA. It is difficult to

imagine a young woman in the United States being stigmatized for wearing pants to

school or work today, even though that was true in the not-too-distant past. The ACA

may help us to achieve a similar level of social acceptance for breastfeeding.

Further Considerations

Another benefit of the ACA provisions relates to cost-savings for employers resulting

from reduced labor turnover. By improving the ability of mothers of infants to both

breastfeed and maintain employment, it seems likely that a significantly increased

fraction of women will remain with a given employer following childbirth. Many

women who sought to provide breast milk to their infants have encountered barriers in

the workplace in the past, so have either left one employer to seek employment with

another more family-responsive one, or quit employment entirely. The ACA protections

will make existing jobs more attractive to these women. For employers, any resulting

reduction in employee turnover will reduce labor costs associated with replacing and

training new employees.

The new ACA provisions for expressing breast milk will expand the opportunities

available to many working mothers. Much of the evidence presented here supports the

claim that work has often served as a barrier to breastfeeding. The ACA will reduce,

although not eliminate, those barriers and will serve to help equalize breastfeeding

opportunities across lines of income, age, education, and race/ethnicity.

The ACA breastfeeding protections will help to reduce workplace constraints and may

help ameliorate the stigma currently associated with breastfeeding and expressing

breast milk. But this is not enough. Even with the ACA protections, we will not

achieve the HP2010 objective of 50 percent of new mothers breastfeeding through

six months—much less the new, higher HP2020 objective of 60.5 percent (DHHS

undated). More could and should be done, including:

• legalizing breastfeeding in public places,

• introducing health and safety standards for breast pumps, and

• subsidizing breast pumps and breastfeeding counseling and education,

particularly for low-income mothers.

7 Using ethnographic research, Boswell-Penc and Boyer (2007) uncover evidence suggesting that the stigma associated with expressing breast milk is likely more severe than that associated with nursing an infant directly.

www.iwpr.org 15

The first two possibilities are included in provisions of the proposed Breastfeeding

Promotion Act. The latter supports are already available on a limited basis to mothers

participating in the Women, Infants, and Children (WIC) program.8

It is unfair that the health benefits of breastfeeding have been disproportionately

available to mothers and children of high socioeconomic status. The ACA breastfeeding

protections, as well as the additional policies discussed in this report, can help to

rectify this situation, and make breastfeeding less a matter of privilege and opportunity

and more a matter of unconstrained individual choice for new mothers.

8 See Collins, Rappaport, and Burstein (2010) for counseling provisions and their effects, and page 14 of the document for evidence regarding providing breast milk pumps through the WIC program.

www.iwpr.org16

References

AAP (American Academy of Pediatrics). 2005. “Policy Statement: Breastfeeding and the

Use of Human Milk.” Pediatrics 115 (February): 496–506.

Bartick, Melissa, and Arnold Reinhold. 2010. “The Burden of Suboptimal Breastfeeding

in the United States: A Pediatric Cost Analysis.” Pediatrics 125 (May): 1048-56.

BLS (Bureau of Labor Statistics). 2009. “Women in the Labor Force: A Databook.” <http://

www.bls.gov/cps/wlf-databook2009.htm> (accessed August 26, 2010).

Boswell-Penc, Maia and Kate Boyer. 2007. “Expressing Anxiety? Breast Pump Usage in

American Workplaces.” Gender, Place & Culture 14(5): 551–67.

CDC (Centers for Disease Control and Prevention). 2007. “Breastfeeding Trends and

Updated National Health Objectives for Exclusive Breastfeeding—United

States, Birth Years 2000–2004.” Morbidity and Mortality Weekly Report 56

(August): 760-763.

CDC. Undated. “Final Breastfeeding Rates by Socio-Demographic Factors, among

Children Born in 2006.” <http://www.cdc.gov/breastfeeding/data/NIS_

data/2006/socio-demographic_any.htm > (accessed July 27, 2010).

Collins, Ann, Catherine Dun Rappaport, and Nancy Burstein. June 2010. WIC

Breastfeeding Peer Counseling Study, Final Implementation Report, WIC-10-

BPC. Alexandria, VA: U.S. Department of Agriculture, Food and Nutrition

Service, Office of Research and Analysis.

DHHS (U.S. Department of Health and Human Services). 2000. Healthy People 2010:

Understanding and Improving Health, 2nd ed. November. Washington, DC: U.S.

Government Printing Office. <http://www.healthypeople.gov/publications>

(accessed October 13, 2010).

DHHS. 2010. “Breastfeeding: Common Challenges.” <http://www.womenshealth.gov/

breastfeeding/common-challenges> (accessed August 20, 2010).

DHHS. Undated. “Healthy People 2020 Topics and Objectives, Maternal, Infant, and

Child Health.” <http://www.healthypeople.gov/2020/topicsobjectives2020/

objectiveslist.aspx?topicid=26> (accessed December 6, 2010).

Drago, Robert. 2007. Striking a Balance: Work, Family, Life. Boston, MA: Dollars &

Sense.

Dye, Jane Lawler. 2008. “Fertility of American Women: 2006,” Current Populations

Reports, No. P20-558. Washington, DC: U.S. Census Bureau.

www.iwpr.org 17

Fein, Sara B., and Brian Roe. 1998. “The Effect of Work Status on Initiation and Duration

of Breastfeeding,” American Journal of Public Health 88 (July): 1042–46.

Galinsky, Ellen, James T. Bond, and Kelly Sakai. 2008. The National Study of Employers.

New York: Families and Work Institute. <http://familiesandwork.org/site/

research/reports/2008nse.pdf> (accessed October 13, 2010).

Galtry, Judith. 2000. “Extending the ‘Bright Line’: Feminism, Breastfeeding, and the

Workplace in the United States,” Gender and Society 14(2): 295–317.

Golden, Lonnie, and Helene Jorgensen. 2002. “Time After Time: Mandatory Overtime

in the U.S. Economy,” Briefing Paper, No. 120. Washington, DC: Economic

Policy Institute.

Guendelman, Sylvia, Jessica Lang Kosa, Michelle Pearl, Steve Graham, Julia Goodman,

and Martin Kharrazi. 2009. “Juggling Work and Breastfeeding: Effects of

Maternity Leave and Occupational Characteristics.” Pediatrics 123(1): e38–e46.

Haider, Steven J., Alison Jacknowitz, and Robert F. Schoeni. 2003. “Welfare

Work Requirements and Child Well-Being: Evidence from the Effects on

Breastfeeding.” Demography 40(3): 479–97.

Han, Wen-Jui, Christopher J. Ruhm, Jane Waldfogel, and Elizabeth Washbrook. 2008.

“The Timing of Mother’s Employment after Childbirth,” Monthly Labor Review

131: 15–27.

Henrici, Jane M., Allison Suppan Helmuth, Frances Zlotnick, and Jeff Hayes. 2010.

“Women in Poverty During the Great Recession,” Briefing Paper, No. D493.

Washington, DC: Institute for Women’s Policy Research.

International Labour Organization. 2000. “C183 Maternity Protection Convention,

2000.” Geneva, Switzerland: International Labour Organization. <http://www.

ilo.org/ilolex/cgi-lex/convde.pl?C183> (accessed August 24, 2010).

Ip, Stanley, Mei Chung, Gowri Raman, et al. 2007. Breastfeeding and Infant and

Maternal Health Outcomes in Developed Countries. Evidence Report/

Technology Assessment No. 153. Rockville, MD: Agency for Healthcare

Research and Quality.

Jacknowitz, Alison. 2008. “The Role of Workplace Characteristics in Breastfeeding

Practices,” Women and Health 47(2): 87–111.

McGill Institute for Health and Social Policy. 2010. “The Work, Family, and Equity

Index( (WFEI): Measuring governmental performance around the world.”

<http://raisingtheglobalfloor.org/policies/single-country-1.php?country=United+

States+of+America> (accessed August, 20, 2010).

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McKinley, Mary Nita, and Janet Shibley Hyde. 2004. “Personal Attitudes or Structural

Factors? A Contextual Analysis of Breastfeeding Duration.” Psychology of

Women Quarterly 28 (December): 388–99.

National Center for Health Statistics. 2010. Health, United States, 2009 with

Special Feature on Medical Technology (DHHS Publication No. 76-641496).

Hyattsville, MD.

National Bureau of Economic Research. Undated. “CPS Merged Outgoing Rotation

Groups.” <http://www.nber.org/data/morg.html> (accessed July 28, 2010).

Ortiz, Joan, Kathryn McGilligan, and Patricia Kelly. 2004. “Duration of Breast Milk

Expression Among Working Mothers Enrolled in an Employer-Sponsored

Lactation Program.” Pediatric Nursing 30(2): 111–19.

(PPACA) Patient Protection and Affordable Care Act, 2010. H.R. 3590, 111th Congress.

<http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=111_cong_

public_laws&docid=f:publ148.pdf> (accessed July 28, 2010)

Rosin, Hanna. 2009. “The Case Against Breast-feeding.” The Atlantic, April. <http://

www.theatlantic.com/magazine/archive/2009/04/the-case-against-breast-

feeding/7311> (accessed August 23, 2010).

Schwarz, Eleanor B., Roberta M. Ray, Alison M. Stuebe, Matthew A. Allison, Roberta B.

Newss, Matthew S. Freiberg, and Jane A. Cauley. 2009. “Duration of Lactation

and Risk Factors for Maternal Cardiovascular Disease.” Obstetric Gynecology

113(5): 974–82.

U.S. Census Bureau. 2010. “Poverty Data” <http://www.census.gov/hhes/www/poverty/

data/index.html#cps> (accessed October 13, 2010).

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Time for Nursing Mothers under the FLSA.” <http://www.dol.gov/whd/regs/

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index.html> (accessed December 14, 2010).

www.iwpr.org 19

Appendix: Data and Methodology

The 2009 ASEC data are used for ACA coverage estimates. Hourly status serves as a

proxy for nonexempt as opposed to exempt status under the FLSA overtime provisions.

Although the correlation between hourly and nonexempt status is not perfect, as a

practical matter most employees and employers associate hourly status with payment

for overtime hours beyond 40 per week. As an empirical matter, Golden and Jorgensen

(2002) report a U.S. Department of Labor Wage and Hour Division estimate that 66.8

percent of wage and salary workers were covered by the overtime provisions of the

FLSA in 1999. The 1999 Merged Outgoing Rotation Group data from the Current

Population Survey, provided by the National Bureau of Economic Research (NBER),

shows 58 percent of wage and salary workers being paid on an hourly basis. The

difference suggests that the hourly proxy understates the extent of ACA coverage,

perhaps by as much as nine percentage points.

The ASEC does not provide data on employer ownership of multiple worksites, while

the Department of Labor rules for the ACA protections use the sum of employment at

all or multiple sites to establish whether 50 individuals are employed. Therefore, many

individual establishments with fewer than 50 employees will be covered by the ACA

protections. Further, many small employers will not seek an exemption, implying that

even more employees in small establishments will be covered. We therefore estimate

that, on average, women employed hourly in establishments with more than 10

employees will be covered by the breastfeeding protections of the ACA.

The ASEC data are weighted by the population weights provided by the U.S. Census

Bureau to estimate mean rates of ACA coverage for the various demographic groups.

To estimate the number of women covered by the ACA, we constrain the ASEC

estimates to the number of employed women, ages 16 to 44 years, yielding a figure of

35,386,345. Of that population, the proportion of women paid hourly and employed in

establishments with at least 10 employees, is 52.9 percent, as calculated from the ASEC

data, so an estimated 18,706,175 women are covered by the ACA provisions.

U.S. Census Bureau estimates from the American Community Survey for 2006 show

4,182,942 women giving birth during the 12 months prior to survey administration,

noting that twins and high-order births count as a single birth event (Dye 2008). A

subsample of 2,109,291 women (50.4 percent) was estimated to be employed at the

time the survey was administered. That figure represents an average employment rate

for all mothers of infants. The analysis here, however, requires information on mother’s

employment at any time up to the point where the child reaches six months of age,

and a recent study suggests that the 50.4 percent figure understates employment at that

point because so few women are employed during the first (7 percent) or second (26

percent) month after childbirth (Han et al. 2008). Consequently, some of the employed

women are in fact self-employed, and should be excluded from the estimates. In 2008,

www.iwpr.org20

only 5.2 percent of all employed women were self-employed (BLS 2009). We assume

the sources of under- and over-estimation roughly cancel each other out.

Of the 2.1 million employed mothers of infants, we estimate that 1.1 million (52.9

percent) will be covered by the breastfeeding provisions in the ACA, assuming that

2006 birth rates are indicative of future fertility. The evidence from the research

literature reported in the first two sections of the report suggests that rates of

breastfeeding through six months for women employed on an hourly basis have

historically fallen below rates for the general population (43.5 percent). A study of

new mothers in California found that employment is associated with a 15 percentage

point lower rate of breastfeeding (Guendelman et al. 2009, p. e43). Given that around

half of all mothers are employed, it is reasonable to view the 43.5 percent national

figure as an average of 36 percent among employed mothers and 51 percent among

nonemployed mothers (reflecting the 15 percentage point difference). The 36 percent

figure is probably overstated as an estimate for hourly workers, given salaried workers

are more likely to breastfeed. Nonetheless, we use this information as the best available

figure to represent the proportion of new mothers who are employed hourly and would

breastfeed through the six-month period absent the ACA provisions. If the rate for

hourly employees is even lower without the ACA protection, then the projected effect

of the ACA provision would be even larger.

Regarding the extent to which the ACA protections will raise the rate of breastfeeding,

the study of an intervention in five corporations found that, among employed mothers,

those paid on a salary basis reported expressing breast milk at a rate of 79 percent,

whereas those employed on an hourly basis reported a rate of only 66 percent

(Ortiz, McGilligan and Kelly 2004); the latter is relevant to the likely behavior of

the population covered by the ACA provision. Even the 66 percent figure, however,

is likely an overestimate of ACA effects given that it resulted from a more extensive

intervention than that flowing from the ACA (e.g., it included counseling and providing

a pump). It therefore seems reasonable to assume that the rate of breastfeeding at six

months in the relevant population would rise from 36 percent to 51 percent, or traverse

half the distance from 36 percent to the 66 percent figure. Assuming that 51 percent

of hourly employed mothers, 51 percent of nonemployed mothers, and 36 percent of

salaried mothers will breastfeed as a result of the ACA protections, projections yield an

average rate of breastfeeding of 47.5 percent at six months.

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